If, Why, and When Subjective Well-Being Influences

Applied Psychology: Health and Well-Being, in press. (Preprint, 2017, in press.) Copyright the authors. Creative Commons open access: Attibutional, nonderivative, noncommercial.

If, Why, and When Subjective Well-Being Influences Health, and Future Needed Research

Ed Diener University of Virginia and University of Utah and The Gallup Organization

Sarah Pressman, John Hunter, and Desi Chase University of California at Irvine

KEYWORDS: Subjective well-being; health; happiness; positive affect

Abstract

We review evidence on whether subjective well-being (SWB) can influence health, why it might do so, and what we know about the conditions where this is more or less likely to occur. This review also explores how various methodological approaches inform the study of the connections between subjective well-being and health and longevity outcomes. Our review of this growing literature indicates areas where data are substantial and where much more research is needed. We conclude that SWB can sometimes influence health, and review a number of reasons why it does so. A key open question is when it does and does not do so – in terms of populations likely to be affected, types of SWB that are most influential (including which might be harmful), and types of health and illnesses that are most likely to be affected. We also describe additional types of research that are now much needed in this burgeoning area of interest, for example, cross-cultural studies, animal research, and experimental interventions designed to raise long-term SWB and assess the effects on physical health. This research area is characterized both by potentially extremely important findings, and also by pivotal research issues and questions.

Literature reviews and meta-analyses of his life and current situation as good and the scientific literature have generally concluded desirable versus undesirable and negative? that subjective well-being (SWB) can be These evaluations can be either in terms of beneficial to health and longevity. Our aim is to cognitive reflections, representing reflective give a broad overview of the research and appraisals of life and domains of life such as reviews in this area, including the mediators and work, or can be in terms of affect. The person's moderators that help explain the effects of SWB affect includes feelings of various types, on health, as well as the various research including emotions and moods. Positive affect methods that have been used. Our review is includes the various feelings people experience designed to help scientists see more clearly when things seem to be going well, and negative where important research is needed in this field. affect is the experience that things are not going well. Positive affect includes both momentary Subjective Well-Being emotions such as enjoyment, and more chronic long-term moods such as contentment. Negative Many different terms are used in the affect includes momentary or "state" emotions psychology literature to describe well-being. such as feelings of anger, sadness, stress, and Readers are referred to Diener, Oishi, and Lucas worry, and also longer-lasting moods such as (2017) for more extensive detailed coverage of depression that occurs over time. Another form this topic. "Psychological well-being" is the of SWB is "optimism," which often correlates broadest and most all-inclusive term. It includes with positive affect, but includes positive "Subjective well-being," which is how expectations about the future. individuals evaluate or appraise their own lives. Often a distinction is made between To what degree does a person evaluate her or reflective forms of SWB and the experience of Psychological Well-Being and Health 2 momentary SWB, although the two are information and studies are missing from the correlated. Another form of psychological well- current literature. being that has been assessed in this area is 4. To review the literature within the "eudaimonic" well-being, which includes framework of complex system dynamics, in variables such as meaning and purpose in life, which the key variables are both influenced by supportive social relationships, and feelings of and influence other key variables. In this mastery. There is an ongoing debate about the framework it is essential to search for the distinctiveness of various types of SWB, but this mediators of the SWB and health association, as topic is beyond the scope of the current review. well as the moderators that make the effects In this review we examine the relation of stronger or weaker. Furthermore, it is essential different forms of SWB, such as life to understand statistical controls in conceptual satisfaction, positive affect, optimism, and low terms, and not merely as the control of negative affect, with health and longevity. As potentially confounding variables. In general a will be seen, there is still much to be learned more sophisticated approach to statistical about the overlapping versus distinct influences control of possible confounds could be helpful of the types of SWB on health. in this field. A dynamic systems approach alerts Our review is focused on the effects of us to the fact that some variables that are treated somewhat enduring stable levels of SWB rather as confounds in this literature can be causes or than on the effects of momentary moods. effects of SWB, and therefore it is risky to However, the effects of moods can be quite automatically treat them as confounds. informative because they often indicate how SWB exerts its effects. We do not focus on The Value of Multiple Research Methods mental health in this review, as it is covered in other reviews. However, there is substantial Each type of research method has overlap between many of the mental health strengths compared to the other methods, and measures that have been used and what we therefore conclusions drawn from each method define as negative affect. are useful. More complete understanding of the dynamic system connecting SWB to health can Purposes of this Review be gained if we consider, in addition to the knowledge gained from correlational, In light of the fact that a number of experimental, and longitudinal designs, reviews and meta-analyses of this area have nonhuman animal studies, as well as factors been published, there are several purposes of the such as mediation, moderation, causal modeling, current review: and short- versus long-term mood effects. Some 1. To examine recent evidence, as well laboratories rely exclusively on one method, as other types of evidence such as research on although a more catholic approach to methods SWB and genetic markers, and SWB effects in might aid in the understanding of the issues they animal health that have not been adequately are addressing. Below we list some of the reviewed in the health context. strengths and limitations of each of the various 2. To review how evidence drawn from methodological approaches. different types of research methodologies each A. Correlational methods are relatively adds to our understanding of the pathways by quick and inexpensive compared to most other which SWB can influence health. methods. Simple cross-sectional correlations 3. To use our multi-method review to between SWB and health can be used to show where the important gaps are in the examine a spectrum of associations across large literature and the biggest areas in need of more and diverse subject samples. Such correlations research. By comprehending what each method can reveal the generality of the associations, and adds, we can determine what types of statistical controls of additional variables can Psychological Well-Being and Health 3 help understand the linkages in the system. similarly, we cannot alter behaviors in a health Correlational methods allow us to discover links damaging manner (e.g., inducing smoking). in the SWB and health system in a cost-effective Furthermore, because of the large stakes of and methodologically simple manner that can studies experimenting on important health focus and give direction to more intensive later outcomes (e.g., disease survival or longevity), it studies. is growing more difficult to maintain adequate B. Experimental studies can reveal control groups and hold off providing causal connections in a strong way that is participants with treatments and manipulations usually not available when using the other known to be effective in improving wellness methods. However, these methods often only outcomes. Because medical researchers work tell us whether an association can occur, but not with similar constraints, they have long whether it is a major causal connection in the embraced the importance of non-experimental natural world. Furthermore, experiments research as useful, functional, and essential. frequently do not make clear the context or Another pragmatic limitation to long-term border conditions that must be present for the experimentation is that it is difficult and very connection to occur. Furthermore, often it costly to change people's long-term levels of appears that the manipulated variable has an SWB in a way that can influence future disease effect, but we do not know why some and mortality outcomes, or reverse the effects participants are affected and others are not. We that have already occurred. also do not know about the generalizability of A final issue should be mentioned in the findings to other cultures, populations, terms of experimentation, and that is that situations, and personalities. It is possible to philosophers, going back to Aristotle, discover these things through repeated differentiate several types of causality – it is not experiments across many settings, samples, and a single thing. The type of causality that is cultures, but this is often not the most efficient studied with experimentation is concerned with initial step. whether actions we take change the likelihood Scientists who rely heavily on of an outcome. The experimental methods as experimentation sometimes criticize other typically used do not tell us whether the thing methods because in using those methods one we manipulate is necessary or sufficient for the can never control all possible confounding outcome, and often do not reveal the mediators, variables, although one can frequently control how the events unfold over time, or the the most obvious and seemingly important ones. moderator and context conditions required for However, a parallel problem with the outcome to occur. experimentation is that the scientist can usually C. Prospective longitudinal studies can not be certain what all is being changed by the tell us whether one variable predicts another intervention, and what the active component is variable later in time, and whether changes in with certainty. For instance, interventions to the first variable are followed by changes in the raise well-being can alter factors such as social second. These studies complement experiments. relationships and meaning and purpose in Although not possessing the same internal participants' lives, both of which might be validity in terms of causal inferences, they have responsible for health effects independently of the strength of being able to determine a SWB. sequence of events in the natural world. Possible Health research experimentation in confounding variables can be assessed and particular comes with its own unique set of analyzed. Furthermore, longitudinal methods limitations. Given the goal to not harm research can reveal the unfolding of dynamic systems participants, there are few illnesses that we can across time, as well as patterns over many years experimentally give to a participant (see Cohen and even decades. However, it is often argued et al., 2006, on influenza for exceptions), and, that causality cannot be determined with as Psychological Well-Being and Health 4 much rigor as in experiments because one best tool for answering specific questions most cannot be certain that all potentially efficiently. Instead of awarding gold-standard confounding variables have been controlled. status invariably to experimentation, we suggest D. Mediators, moderators, and causal that the gold standard should be the method that modeling analyses seek to determine the best fits the questions being addressed. While intervening processes that explain causal experimentation offers perhaps the most rigor in connections, as well as the broader dynamic terms of control, correlational studies are often a system that must be in place for it to occur. more efficient way to answer initial inquiries, Mediational analyses seek to explain why SWB and developmental longitudinal studies can influences health by examining the behavioral answer questions that are very difficult to and physiological outcomes of SWB that might address with experimentation alone. in turn influence health. Moderator analyses and Furthermore, the type of causal knowledge causal modeling seek to determine the other provided by experimentation needs to be contextual variables that must be in place for the supplemented with information on mediators, causal sequence to occur, or which make it a moderators, and considerations of the entire stronger or weaker connection. In causal dynamic system that is involved in health. modeling we can also seek to understand the We suggest that a broad approach is bidirectional nature of causal influences. needed – Scientific Understanding Through To understand behavioral systems we Multiple Methodologies (SUMM). In this must gain insight into the proximal versus distal approach we recognize that the phenomena in influences on an outcome, and understand that the field of human behavior and health occur in these influences might be related not only complex and dynamic systems, and that the best separately to the outcome, but also directly to way to gain a fuller understanding of these each other. It also is essential to differentiate systems is by using different methods for possible third-variable explanations of the SWB different aspects of the inquiry. One can ask and health association from factors that might whether fields that have become too enamored cause or result from SWB and be an important with experimentation have produced laboratory aspect of understanding the effects of SWB. knowledge without knowing how much it E. Animal research is rare in the SWB explains phenomena outside of the laboratory. and health area, but is becoming more We believe SUMM can offer the scaffolding for commonplace. It has the advantage that some of using different methodological approaches to the confounding variables that are troublesome gain an integrated explanation of phenomena for human research can be controlled in animal occurring in complex systems. research, such as differences in nutrition and the environment. Furthermore, experiments are Previous Reviews sometimes ethically permissible in animal research that cannot be conducted with humans, In reviewing the studies we cite meta- allowing for stronger inferences to be made. analyses of that area where they are available, to Finally, animal research helps us generalize the insure a more comprehensive and systematic findings found in humans. review of each issue. Tables 1 through 9 of this The type of methodology used by paper, and the supporting references, can be researchers should be chosen based on the found in the Appendix. Because meta-analyses, questions being asked and goals of the research, with their systematic location of publications rather than on a continuum of better and worse and their objective method of summarizing methods. One's initial research question, results, are methodologically often stronger than hypotheses, and goals of the inquiry point to the simple literary reviews, in Table 1 first are listed best method for a particular study. In this review the meta-analyses of various areas that have we assume that each method is sometimes the been conducted, and then traditional literature Psychological Well-Being and Health 5 reviews. It can be seen that various types of See Table 2 in the Appendix SWB ------even when statistical controls are applied and See Table 1 in the Appendix the observed association is clear, researchers are ------unable to determine the direction of the have been found to be associated with longevity relationship. This bidirectional uncertainty and various health outcomes. The results occur limits the causal inferences that researchers are across the meta-analyses and literary reviews, able to claim. although are not found in all studies. The strength of the correlational In the following sections of this paper methodology is that it can be used to discover we describe in the Appendix findings from a initial associations between variables gleaned number of individual studies to give readers a from large-scale, representative samples that can clear idea of the research that has been often be gathered quickly and easily, or acquired conducted. Our aim is to give readers a broad from secondary sources. Efficiency, practicality, overview of the various methods and types of data collection and analysis on a global scale are evidence that are available, with the goal of a few of the major advantages of this method. describing the most needed research at this time. Furthermore, researchers usually are able to What we hope to achieve in this article is giving gather relevant data without crossing ethical a broad view of all the types of evidence that boundaries. now exist, both in terms of methodologies and also in terms of mediation and moderation. By Longitudinal Studies taking a broad approach we are able to view the effects of various forms of SWB, and how the Using longitudinal methods allows outcomes of various methods do or do not researchers to determine not only a temporal converge. We hope to indicate where more ordering of events – whether SWB levels rigorous, large-scale, and probing research is predict future health and mortality – but also needed. whether a change in SWB over time predicts a One area we cover is desirable ways to conduct change in health. Furthermore, these methods statistical analyses in this field, and especially in allow us to examine the natural unfolding of the area of controlling possible confounding developmental variables over long periods of variables. Our suggestions are applicable to new time. Because many health conditions occur research, but should also apply to re-analyses of over many years or even decades, it is virtually existing data sets. impossible to examine their causes using only Cross-Sectional Correlational Studies experimental methods. Furthermore, whereas experiments ask whether an association can In Table 2 we present a few examples of occur, longitudinal designs observe this cross-sectional correlational studies. It can be association over time in the natural world – seen in Table 2 that the correlational studies are whether the association does occur. quite diverse. Associations have been found Longitudinal methods allow us to view the across nations between SWB and general health, effects of SWB in natural circumstances in as well as SWB and specific health and interplay with other conditions that influence physiological variables. Immune, health. In Table 3 we present examples of cardiovascular, and endocrine measures have all studies of SWB and health that have used been found to be associated with several forms longitudinal designs. The studies generally show of SWB. The examples of studies in Table 2 that various types of SWB are associated with make evident that in correlational studies, greater longevity and superior health outcomes. However, we will see later that these desirable ------Psychological Well-Being and Health 6 outcomes are not found for all groups of people (2005) reviewed experimental evidence for the across all studies. influence of SWB on health. In Table 4 are ------listed experimental trials designed to raise long- Insert Table 3 About Here term SWB and measure changes in health and ------health behaviors, with over half being published Longitudinal studies provide evidence since the that SWB can influence both health and ------mortality, but with the caveat that other See Table 4 in the Appendix uncontrolled factors might be causing the ------observed association. Even when controlling for Lyubomirsky et al. review. a variety of possible third variables (e.g. It can be seen in Table 4 that a number genetics, income) SWB frequently predicts of randomized controlled trials have now been future health. Yet, even with statistical controls conducted in which people's well-being is raised longitudinal studies do not with certainty rule and positive health benefits ensue. Both out third variable explanations of the findings. reductions in negative affect and increases in There might always be other unobserved positive affect have been found to be related variables that are responsible for the association. both to health behaviors and disease outcomes. Thus, we need additional methods to fully However, there are many limitations in the resolve the third variable problem and firmly existing literature on experimental interventions establish directionality. aimed at increasing SWB and assessing the Longitudinal studies are often costly, effects on health. The time frame of when have problems with attrition of participants, and treatments that improve people’s moods will the most appropriate measures may change as actually produce tangible benefits to health and time progresses (Cohen et al., 2006). reduce the risk of mortality is not understood. Furthermore, many of the meta-analyses find Many psychological interventions seem only evidence of publication bias. One possible modestly effective because many of the health solution to this problem includes the problems (e.g. smoking or obesity related examination of dissertations where the demand illness) may have occurred over such a long for significant results is lower. Furthermore, time that it is difficult to counter them. Also, it fail-safe studies suggest that the existing can be challenging actually to change people's findings are probably valid and not simply due long-term SWB because of the environmental to chance. Most of the studies confirmed and personality factors that may be impediments predictions even when sociodemographic to change. variables were controlled. The majority of experiments designed to raise long-term SWB are focused on people Experiments Designed to Raise Long-Term with chronic medical or mental conditions. This SWB and Determine the Effects on Health leaves open numerous opportunities for future researchers to discover interventions that Long-term experiments on SWB and improve health outcomes in healthy community- health or longevity include randomized based samples. Interventions to reduce negative assignment of participants to conditions and the states such as depression, stress, and anxiety inclusion of control groups. This method is have received a vast amount of research implemented to examine the effectiveness of attention from mental health researchers. psychological interventions to benefit health However, newer studies also have been focused outcomes. These studies have the strength of on raising positive emotions, and a number of occurring in the natural world, as well as the these treatments are promising (e.g., Friedman control and greater certainty that comes from et al., 2017; Kushlev et al., 2017; Moskowitz et randomized controlled trials. Lyubomirsky et al. al., 2012; Parks & Biswas-Diener, in press; Psychological Well-Being and Health 7

Proyer et al., 2014; Seligman et al., 2005). Sin should be the target of the intervention because and Lyubomirsky (2009) present a meta- it is likely to affect health? In some cases this analysis of the SWB treatments' effectiveness in might be life satisfaction or positive affect, and altering levels of SWB, and a number of in other cases it might be the reduction of stress. interventions appear to have exerted a beneficial Furthermore, SWB interventions that continue influence. Positive interventions, alone and in over time seem most likely to produce long- combination with treatment to also lower term results. negative emotions, are an opportunity for health researchers to not only raise people's quality of Research with Nonhuman Animals life, but also to experimentally test the SWB and health connection. Although research with animals has been As with all research approaches, there very helpful in many health related areas of are challenges with intervention studies research, this type of method is rare in the area designed to raise well-being. Challenges of real- of SWB. Animal studies have several world experimentation include creating advantages, including generalizing findings appropriate control groups, complications with more broadly than only to humans. In addition, random assignment to conditions, and researchers with animals can often control differential attrition between the experimental factors that confound conclusions based on groups. In addition, there is not yet a consensus human research. Besides ratings of caretakers, on what interventions are most likely to lead to animal emotional states have been assessed by long-term improvements in SWB. It is not methods such cognitive bias measures, known whether treatments would be more vocalizations, and physiological methods such effective if they were targeted at the as studying cortisol levels, cortical perfusion, requirements of individual participants rather and neuron activity. Behavioral indicators of than the current one-size-fits-all approach. The well-being can also be assessed. For example, current studies investigating experiments Harding et al. (2004) showed that biased designed to raise SWB are few, based on responding to stimuli can reveal negative relatively small samples, and have not examined emotional states in rats just as such biases do in an array of health outcomes. humans. Shortcomings notwithstanding, the Research on animal samples supports the experiments altering long-term SWB have link between psychological well-being and advanced the field of well-being and health by wound healing; rats which had an enriched suggesting that improvements in well-being at environment and were not isolation-reared least in some cases may improve health showed quicker wound healing than their parameters. A number of recommendations can counterparts (Vitalo et. al, 2009). Conclusions be made. First, much of the research takes a from research on inflammation are confirmed by casual approach to selecting SWB interventions, research on rodents suffering stress from social without considering whether they are the most defeat, revealing an up-regulation of effective with this population. A serious inflammatory markers (Powell et al., 2013). shortcoming is that the interventions have often Chronic stress is widely known to produced only small changes in SWB, and negatively influence a number of health-related therefore it is not surprising when health factors in animals, such as reduced reproduction outcomes are not found. Second, the time course (Moberg, 1985) and disturbed cardiovascular of the interventions and outcomes needs to be function (Henry & Stephens-Larson, 1985). carefully considered. Can changes in SWB alter Animals under stress are immune-compromised the course of physiological indicators, or of and therefore more open to disease (Marchant- disease manifestations in the time under study? Forde, 2015). In his popular book, Why Zebras Another issue is to consider which type of SWB Don't Get Ulcers, Sapolsky (1994) explains how Psychological Well-Being and Health 8 short-term stress can be adaptive for animals in cardiovascular system (e.g., Fredrickson et al., the wild, but can be detrimental to health when 2000). it is chronically felt over time. The animal It is imperative to discover what is findings support the conclusions from studies happening physiologically that allows increases with humans, suggesting that stressful and in SWB to ultimately manifest itself as better negative states can interfere with healthy health. For example, high levels of well-being physiological functioning. may positively alter cardiovascular function There is only a very small amount of (e.g., heart rate), and those improvements in the animal research on positive emotions and health cardiovascular system will ultimately lead to in the absence of chronic stress. Weiss et al. better health outcomes (Howell et al., 2007). (2011) found that orang-utans rated as higher in The influence of different types of SWB may be subjective well-being by zookeepers (based on mediated for different physiological systems by their estimates of positive moods, social life, different intermediaries. For example, while the and ability to reach desired locations, and reach immune system might affect many different desired objects) tended to live a human types of illness outcomes, the beneficial equivalent of 11 years more than the less happy behavior of sunscreen use might most influence apes (1 S.D. above versus 1 S.D. below the the decreased likelihood of experiencing skin mean). The Ben-Shaanan et al. (2016) study on cancer. stimulation of the reward system and immune There are several approaches to strength in rodents described in Table 6 is an uncovering mediation. First, we can use simple impressive study of how positive feelings might correlational methods, and use statistical be tied to health parameters. It is evident that techniques to determine whether a possible work with varying levels of well-being in mediator can account for the covariation animals, including across the positive spectrum, between SWB and health outcomes. An is an area in need of future research. extension of simple correlational approaches is to test causal models, and often compare various Mediators of the SWB and Health possible models for the best fit. Causal models Relationship often include measures of a number of influences on health, as well as more than one In order to fully understand how and possible mediator. They may also include why SWB affects health and longevity, the several health outcome measures. By including mediators of this relationship must be a number of variables in the model researchers understood. That is, we need to understand what hope to gain a more realistic picture of how links the experiences of well-being to physical dynamic systems operate in the world. health outcomes. Ong (2010) reviewed a Furthermore, these approaches are capable of number of ways that SWB may influence health taking the error of measures into account in and mortality, and concluded that health determining pathways of influence. behaviors (e.g., better diet, regular exercise, and A second approach to determining improved sleep), physiological systems (e.g., mediation examines how SWB, possible cardiovascular and immune systems), and stress mediators, and health vary over time within (exposure or undoing) are primary candidates individuals. Data collection methods such as for mediators in the relationship. In terms of experience-sampling and ambulatory undoing the sequelae of negative emotions, monitoring techniques have been developed to research shows that positive emotions make document physiological and SWB information people more resilient to stress, with the ability in real time in the natural environment. In the to bounce back in mood and physiology more momentary measurement methods researchers quickly after a stressor affects their can determine whether moods and various physiological parameters that might influence Psychological Well-Being and Health 9 health change together in a predictable way outcomes. In terms of theoretical explanations within individuals. for the connection, Black and Garbutt (2002) Besides cross-sectional correlations and explain why stress leads to inflammation, which momentary ecological methods, short-term can harm health when it is chronic. laboratory and ambulatory experiments demonstrate that manipulations of mood can be Endocrine System Mediators accompanied by health-relevant physiological patterns. The experimental methodology uses Certain hormones appear to be affected various tools (e.g., stimuli embedded in videos by SWB and momentary moods. Cortisol is or tasks) to temporarily activate specific frequently associated with stress and positive emotions in order to disentangle the relationship affect with lower levels of cortisol (Steptoe, between the activated mood and other variables. O'Donnell et al. (2008), including in mood The effectiveness of various mood induction experiments (Buchanan et al., 1999; manipulations is reviewed by Joseph et al. Kirschbaum et al., 1993). Brummett et al. (2017). (2009) found that positive affect was inversely related to levels of norepinephrine and cortisol Cardiovascular System Mediators after awakening. Insulin levels may also be Consistent associations are found affected by moods. For example, Skaff et al. between SWB and cardiovascular functioning, (2009) showed that negative affect predicted which in turn is related to health, cardiovascular rising blood glucose levels the next day, while events, and mortality. In Table 5 are listed glucose one day did not predict moods the next examples of studies that explore the associations day. of SWB and physiological and health outcomes, The endocrine changes are relevant to and a few sample studies showing the the cardiovascular and immune changes physiological measures are related to health. As discussed above. Sympathetic altering hormones can be seen, the association of SWB and (catecholamines) and hypothalamic pituitary ------adrenal cortical axis hormones such as cortisol See Table 5 in the Appendix play a role in regulating these other systems, ------and may be an early step in SWB altering the cardiovascular health has been found for short- health-influencing mechanisms. There are other term emotions and physiological patterns at the hormones that also could be important in the moment that are beneficial to long-term health, SWB and health connection but they are as well as for long-term levels of SWB and relatively understudied in this area (e.g., SWB cardiovascular health. and oxytocin and sex hormones). Finally, interesting hypotheses about cannabinoid Immune System Mediators receptors and endorphins may be relevant to positive emotions, but it is too early to In Table 6 we present example studies determine how they might help explain the showing an association of SWB and immune SWB and health association other than their measures, as well as a few studies revealing that connection to pain. immune function influences health. Based on these studies SWB and Telomeres ------See Table 6 in the Appendix Telomeres are protective endcaps on ------DNA and they protect it from damage during and others it seems plausible that boosted replication. They become shorter as people age immune function is a mediating variable that and telomerase helps rebuild telomeres. The two helps explain how SWB influences health are important in maintaining cell health and Psychological Well-Being and Health 10 fidelity in terms of cell replication. While isolated environment show faster wound healing absence of telomeres is associated with cell (Vitalo et. al, 2009). senescence, lack of telomerase has been In individuals recovering from surgery, associated with conditions such as diabetes those who receive psychological interventions mellitis and poor insulin production. Stressful such as guided imagery, breathing exercises, or conditions have been found to be related to stress management training were found to heal shorter telomeres in both children and adults more quickly (Broadbent et. al, 2012). Married (Drury et al., 2014; Epel et al., 2004). Children couples in an experimental paradigm healed living in difficult, stressful conditions have been more slowly when they were in the conflict found to have shorter telomere length (Mitchell condition than in a supportive interchange et al., 2014). Conversely, Jacobs et al. (2011) condition (Kiecolt-Glaser et al., 2005). Dental found that meditation was associated with students who were given a standardized wound greater telomerase in immune cells, and this was healed more quickly during the summer mediated by the effects of the practice on compared to while undergoing the stress of final increasing feelings of control and decreasing examinations (Marucha et al., 1998). neuroticism. The authors suggested that activities that raise people's sense of well-being Health Behavior Mediators can have substantial effects on fundamental physiological processes. Although it is early in People high in SWB often perform the history of research in this area and there are healthier behaviors, and this mediational few studies, the findings are promising in pathway may be a major cause of their greater offering a direct tie from psychological well- health and longevity. In Table 7 we present being to aging and health at the cellular level. examples of studies on SWB and healthy behaviors. The Table shows that SWB has been SWB and Wound Healing found to be associated with health ------Wound healing is interesting because it See Table 7 in the Appendix involves a number of different systems working ------together in an intricate pattern. Although it is behaviors in many studies. Although a few often included with immune functioning experimental studies have examined changes in because this is such a core part of healing, other SWB and the changes in health behaviors that processes are also involved. In order for wounds might ensue, more research of this type is to heal, usually vasoconstriction and needed. inflammation are involved, but also In sum, there appear to be a number of revascularization must occur, collagen support mediational pathways through which SWB and tissue growth must take place, and all these affects health: cardiovascular, immune, wound must occur in a specific order over time. One healing, telomeres, endocrine response, and study found that the process of skin-barrier health behaviors. In light of the number of recovery was faster for individuals who had physiological processes influenced by moods greater positive affect (Robles et al., 2009). It and SWB, it would be surprising if there were has also been found that surgical patients heal not health outcomes deriving from SWB. more quickly if they are high in life satisfaction (Kopp et al., 2003). Kiecolt-Glaser et al. (1995) Moderators found that women caring for a patient with Alzheimer's Disease healed more slowly from a When does SWB influence health and standardized wound compared to matched longevity, and when does it not? Across studies controls. Rats raised in an enriched versus SWB and health and longevity are often, but not always related. For instance, DuBois et al. Psychological Well-Being and Health 11

(2015) reported that in 65% of the studies they Moderation by the Population Sampled and reviewed a significant association was found Geographical Region after adjusting for one or more covariates. Thus, in about one-third of the studies a significant Age, sex, and other characteristics of the association was not found, and this raises the population have served as moderators of the issue of moderation. In some cases the connection between SWB and health outcomes. nonsignificant association could be due to lack Examples of studies finding moderation effects of statistical power and other methodological are presented in Table 8. As of yet, compelling considerations. However, in others it might be explanations of the sex and age differences in that no association existed. Thus, it is important the findings have not been to identify the conditions that must be in place ------to allow the SWB and health connection to exist See Table 8 in the Appendix so we can gain a better understanding of the ------factors that circumscribe when a causal offered. Studies of ethnic differences in the association is actually found. These factors are SWB and health association are so rare that do referred to as moderators. not hazard a guess as to their causes. It is likely that the relationship going from SWB to health and longevity varies across Moderation by the Type of SWB various groups and conditions. For instance the relationship between SWB and healthy Another moderator that seems to behaviors could be attenuated in subcultures that influence when SWB will affect health is the strongly proscribe unhealthy behaviors such as type of SWB involved, for example optimism smoking because virtually all people, regardless versus life satisfaction versus negative affect. of their SWB, conform to the healthy normative Examples of studies analyzing moderators of behavior. There are also potential cultural this type are shown in Table 9. It can be seen, differences in the SWB and health connection, for example, that in some instances positive or for example, due to what emotions are negative affect are associated with health considered normal or are valued (Curhan et al., outcomes independently of SWB of the 2014; Miyamoto et al., 2013). For instance, in ------East Asian cultures calm positive emotions are Insert Table 9 About Here preferred over aroused ones, whereas the ------opposite is true in individualistic nations such as other valence. One challenge in separating the the USA. Thus, it might be that calm emotions effects of various types of SWB is that they are are more helpful to health than aroused ones in often substantially correlated. Thus, untangling East Asian societies. Similarly, because pride is their influences statistically requires very large desirable in some cultures and proscribed in samples, and unfortunately many existing others, it might have very different associations studies are underpowered to reliably disentangle with health. Kitayama et al. (2015) found the correlated moderators. Although there are opposite associations between anger expression data to suggest that positive and negative affect and cardiovascular, immune, and cholesterol can exert separable influences, with positive indicators in the USA and Japan. The authors affect sometimes exerting beneficial effects and hypothesized that anger expression is linked to at other times negative affect exerting higher status in Japan, and that this could be detrimental effects. We do not yet understand why it is associated with beneficial the conditions where each might exert the physiological patterns in that culture. The area strongest effects, and why. In addition, it is of culture differences in the SWB and health uncertain whether the means and distributions of association is wide open for needed research. the types of SWB are responsible for the effects that are found. The samples could vary more Psychological Well-Being and Health 12 substantially on one type of SWB than on artery calcification 15 years later, but not to another, for example, but researchers have not progressive calcification at 20 years follow-up. examined this possible explanation. Because health outcomes cover such a wide Furthermore, for variables such as life range of states – from overcoming cancer to satisfaction, optimism, and enjoyment of life we catching a cold – we need to more carefully have virtually no knowledge of the separable analyze the type and intensity of illnesses that versus overlapping effects. There is some are likely to be influenced by SWB, and why. indication that highly aroused positive affect might be harmful to health compared to less Moderation by the Study Characteristics aroused and intense forms of positive affect. Some meta-analytic reviews point to Moderation by the Specific Health Outcomes different outcomes in studies that differ in the research methods used. For example, Howell et Different health outcomes might be al. (2007) found that ambulatory studies in differentially affected by SWB. For example, which subjects were followed across days depression likely influences deaths by suicide, produced the least strong findings, and but it seems less likely that it would affect experimental designs the strongest effects. They deaths by certain genetic diseases. Similarly, suggested that in the ambulatory short-term positive affect might benefit the immune system studies across days that other factors such as life and thus help ward off some infectious diseases events might swamp the effects that can be seen such as influenza, but not counter the effects of in long-term patterns, whereas in experimental others. studies a greater number of extraneous factors In terms of moderation by type of may be controlled. illness, Wikman et al. (2011) found that strokes Measurement is another methodological were associated with substantially lower SWB, factor that can influence whether an association whereas diabetes and cancer were least is found between SWB and health. For instance, associated with low SWB. Howell et al. (2007) Steptoe, Gibson et al. (2007) found that positive in a meta-analysis of 150 experimental, affect measured by experience-sampling was ambulatory, and longitudinal studies found that related to several physiological indicators of affect appeared to influence pain levels, disease healthy functioning, but a global measure of progression, longevity, and immune strength, positive affect was less often related to these but not cardiovascular health or endocrine same parameters. system responses. For health status, well-being In summary, moderators thus far have had a greater impact for both short- and long- been somewhat inconsistent across studies and term outcomes in healthy samples. However, health outcomes, and there have been few well-being more strongly influenced unhealthy systematic attempts at strong conceptual samples in countering disease and increasing understanding of the moderators. For instance survival. for age and for sex we do not have a clear Hoen et al. (2013) found that positive picture of the when and why they influence the affect predicted lower levels of all-cause association of psychological well-being and mortality in patients with coronary artery health, and this is also true of the other disease, but not cardiovascular events. moderators as well. We need more systematic Similarly, Shirom et al. (2010) found that in a analyses of different outcomes resulting from sample followed for 20 years (mean age initially different measures, methods, and distributions was 41.7 years) feelings of vigor predicted and mean levels of the types of SWB before lower mortality and diabetes, but not ischemic firm conclusions can be reached about possible heart disease. Kroenke et al. (2012) found that moderators in this realm. positive affect predicted prevalent coronary Psychological Well-Being and Health 13

SWB and Health Embedded in a Complex that this can control away significant and Dynamic System influential portions of SWB. For behavioral phenomena we can Behavior exists in complex systems always locate distal influences, those occurring where each outcome is influenced by a number in the past or at a distance, and proximal of other variables, and in turn influences other indicators that are closer to the outcome in space variables. Furthermore, at times a variable is and/or time. The distal-proximal distinction is both influenced and influences another variable. important in the SWB and health domain A full understanding of an association such as because some of the variables that are often that between SWB and health must include a controlled as possible confounds in correlational consideration of bidirectional influences, and longitudinal results could be causes of SWB reverse causation, and both distal and proximal (and it mediates their effects on health), influences. outcomes of SWB (and they mediate its effects on health), or they might directly influence Multiple Causation health. Income is a prime example of a variable that can both foster SWB, and in part result It is evident that health and longevity are from it. Thus, simply controlling income as a influenced by many factors, both genetic, confounding nuisance variable, although behavioral, and physiological. These factors informative, can be dangerous if not carefully may be more distal or more proximal from considered within a distal-proximal conceptual health outcomes. For example, income is a more analysis. In analyzing statistical corrections distal influence on health that can have an there is a danger of controlling away valid SWB influence through more proximal influences effects. such as SWB, the quality of medical care, nutrition, and perhaps feelings of respect and Reverse Causation: Health Influencing SWB status. Social relationship variables such as social support versus loneliness can influence Because health can influence SWB, a health through social effects on health behavior, challenge arises in the difficulty of separating as well as possibly on more direct effects on effects in each direction. When we examine physiological indicators relevant to health. longitudinal studies we find evidence for an A challenging issue is that many of the association between worsening health and more distal factors such as income can influence declining SWB. For example, Hubbard et al. both SWB and health. Part of the challenge (2014) found a strong negative correlation comes in that if these variables are controlled as between frailty and SWB in an elderly sample. possible confounding variables, this might Binder and Coad (2013) studied over 100,000 statistically over-control because it removes individuals in the British Household Panel portions of SWB that are relevant to health Survey, and used propensity-matching to create (discussed further below). “treatment” and “control” groups. In this study, Another issue with variables such as decreases in health such as stroke and cancer income and social support is that SWB not only predicted lower SWB. is influenced by them, but also is known to Acute infection can trigger major depression influence them. A number of studies show that (Gunaratne et al., 2013). A small amount of people high in SWB later earn higher incomes experimental work also suggests health effects and have better marriages, for example, and on SWB. Janicki-Deverts, Cohen, Doyle, these associations have been replicated a Turner, and Treanor (2006) infected volunteer number of times. Thus, the danger with the participants with a virus and quarantined them. automatic statistical control of these variables is Daily production of proinflammatory cytokines was related to lower positive affect the next day, Psychological Well-Being and Health 14 but was not related to negative affect. In another (including prenatal nutrition), social study, those receiving a typhoid injection were relationships, and other factors must all be lower in mood several hours afterward, considered if we are to uncover the true nature compared to the control condition (Strike et al., of the SWB and health connection. 2004; Wright et al., 2005). One type of third variable that is Several characteristics of an illness may sometimes overlooked is that of the measures increase the impact of health on SWB, for containing artifacts that might contaminate them example whether it interferes with activities of and lead to misleading conclusions. For daily living. Mukuria and Brazier (2013) found instance, when SWB is assessed by self-report that ability for self-care, ability to carry out surveys and health is also assessed by subjective usual daily activities, and pain were all aspects ratings of health, there is an obvious problem of of health that are related to reports of happiness. contamination of both measures by factors such Graham et al. (2011) found that both as social desirability, positivity, and response interference with daily activities and pain were biases such as number use, leading to a spurious associated with lower SWB. However, the association between the two. Even more researchers also found effects that suggest that problematical, sometimes self-report measures expectancies moderate the effects of health on of health include items such as vigor and energy SWB. For example, they found that difficulties that are also included in measures of SWB. For with daily activities had less impact on older this reason it is important to examine respondents. Income lessened the impact of pain experiments in which SWB or moods are on life satisfaction, but made difficulties with induced, which do not then rely on participants' self-care more impactful. The authors suggest reports of their moods, and to also examine that the latter finding is due to the fact that objective tests of health such as biological and wealthier people have higher expectations in health markers. Objective assessments of health general. Finally, they found that mobility behaviors such as activity tracking and problems had a larger negative effect on men prescription compliance also are very desirable. than on women. In the measurement of SWB we can examine The impact of ill-health on SWB is not a nonself-report measures such as SWB reports on linear function of the objective illness, but the target participant obtained from seems to be heavily influenced by overcoming knowledgeable informants, cognitive and disability to stay involved with other people and response-time measures, experience-sampling, activities. It is important to note, however, that and daily reconstruction measures (DRM) of it is possible that the individual’s level of SWB moods. More diverse methods for assessing is one key determinant of whether they stay SWB would obviate some concerns about involved with others and continue to work and measurement confounds leading to spurious function well. The path from health to SWB is conclusions. frequent enough that it must also be considered One approach to ruling out the influence and analyzed when studying directionality of third variables is through statistical controls between SWB and health. or similar strategies such as participant- matching. An example of statistical controls, Third-Variable Explanations (Confounding and the issues they present, is the study by Liu Variables) et al. (2016) on the Million Women sample in the United Kingdom. The investigators followed Apparent causal influences might be due a large sample of women for ten years after they to some third confounding variable. In the case had responded to a single-item 3-point of SWB and health, there are several culprits happiness scale and observed mortality. The that deserve examination. Sociodemographic initial happiness measure did predict longevity, factors, genetic predispositions, early nutrition but did not withstand the control variables that Psychological Well-Being and Health 15 were then employed—statistical controls for final issue comes from our observations of self-reported health, treatment for anxiety, research on well-being and health. Readers are arthritis, asthma, depression, diabetes, or referred to those original sources, as well as to hypertension, and several sociodemographic and Westfall and Yarkami (2016) and Rohrer lifestyle factors (such as smoking, deprivation, (2017). and body-mass index). One issue of such controls, as discussed below, is that they 1. Undercontrol Because of Error of controlled the effects that SWB had exerted to Measurement that point in time, at about age 50, and thus discarded these effects. Another issue is that When statistically controlling variables factors such as smoking and hypertension can usually we do not control away the full amount be influenced by SWB, and thus controlling of these variables can lead to an underestimation of variance that is due to those variables because the effects of SWB on health. One more issue is they are measured with error. Thus, in in controlling subjective health, the reports of controlling for Time 1 health, for example, our which are likely to be influenced by a control will be incomplete to the extent that our respondent's happiness and positivity, the measure of health contains measurement error. investigators controlled away valid portions of Our measure of SWB is also likely to be SWB. Furthermore, it is remarkable that the affected by measurement error. For example, if findings were as robust as they were, in light of a relatively weak measure of positive emotions the fact that the measure of SWB used was not is used, the underlying true associations might ideal. These issues with statistical controls are be seriously underestimated. Corrections for the discussed below. attenuated reliability of measures are rarely conducted in this literature. This means that we The Challenges of Statistical Control do not fully capture the effects of SWB, or of the potential confounding variables either, when The association between SWB and simple statistical controls are introduced in the health might be because health influences SWB analyses. Because most studies rely on brief or because third variables such as income self-report measures of SWB, often collected at influence both of them. In order to determine only one point in time, underestimation is whether SWB actually influences health, usually a distinct possibility. A measure of SWB researchers often turn to statistical controls in taken at a single point in time will only partially which the possible confound is eliminated capture the long-term effects of SWB on health statistically and the resulting association because SWB does not remain completely stable examined. For instance, to rule out the over time. possibility that SWB is associated with Failure to correct measurement error in longevity only because it is influenced by the some cases can even produce illusory positive person's health at the initial testing, health status findings. If a predictor is measured without as that time is controlled in the association error, such as the treatment condition, and is not between initial SWB and longevity after that. related to the outcome variable, it might appear However, there are a number of serious issues to be associated when potential confounds are when statistical controls are employed, and statistically controlled if they are not corrected these often go unrecognized. For instance, for measurement error. Thus, not controlling for statistical controls can substantially alter the measurement error can lead to both over- and nature of the questions being asked. Below we under-estimation of effects in some instances. describe issues with statistical controls. The first was discussed by Kahneman (1965) and the next two were discussed by Meehl (1970). The Psychological Well-Being and Health 16

2. Systematic Unmatching and SWB or lead to it. Only by using more Unrepresentative Subpopulations sophisticated research designs can researchers hope to accurately estimate the various biases Statistical control is similar to matching and influences. of subjects because we match people It happens very frequently that statistically to compare people who are similar investigators in this area control socioeconomic on the control variables and yet differ on the variables such as income and education, without independent variable. For example, in realizing that factors such as income can be controlling Time 1 health, we seek to identify themselves influenced by SWB. There are now people who are similar in health but different in studies showing that people high in early SWB SWB when we predict longevity. The problem are likely to later earn higher incomes, for is that SWB must be caused, and when one of instance, even when controlling factors such as those causes, for example health, is omitted parental income. Thus, in controlling income the from the system, other factors influencing SWB researchers are possibly throwing out valid must then differ. It is likely that some factor portions of SWB that might be influencing such as temperament must then differ to make health. some people just as happy when they are ill as In behavioral research a number of third- others are when they are not ill. Meehl (1970) variable patterns are recognized and discussed, explains how statistical controls match subjects including third variables as suppressors, on the variables in question, but then unmatch mediators, causes, and outcomes. In the case them in an unintended way on other variables. where third variables cause both the He also explains how statistical controls are independent and dependent variable they may likely to make the sample less representative be confounds when trying to estimate the causal than it was before controls were introduced, by effects of the independent on the dependent weighting certain unusual individuals more than variable. However, there is a danger of the more typical ones. overcontrol in which actual effects are deleted. For third variables that may cause both SWB 3. Causal Arrow Ambiguity and health, it is informative to examine both their direct effect on health, but also their A serious issue is that when we control indirect effects through SWB. It is important to for a possible confounding variable, it might note that when third variables are mediators or overcontrol because it is itself a cause or an outcomes it often can lead to misleading results effect of the independent variable, and therefore when they are controlled. What is important is controlling it removes some amount of the that a conceptual analysis of the system be effect of the predictor. For example, controlling consistent with the way the controls are for health at Time 1 because it is a possible employed. A strength of causal modeling, confound overlooks the fact that it might at that described below, is that the potential confounds time also result from SWB. Therefore, when it can be introduced into the analyses in terms of is controlled it removes valid predictive power different possible relationships, and the results from SWB. determined. In this way one can be more certain In order to separate the direct effects of that the researcher is not spuriously controlling SWB on health, as well as estimate the mediated away true relationships. Furthermore, causal indirect paths, one should use longitudinal analysis demands that researchers carefully measures with path analysis in a cross-lagged consider the pathways that may exist between design. This procedure is needed both to the variables they measure. examine the effects of SWB on outcomes, but also to assess third variables that might confound the results, or that might arise from Psychological Well-Being and Health 17

4. Studying Change in the Rate of Effects, adulthood and to some degree be captured by Not Effects Per Se Time 1 measures of health. In this case controlling for T1 health truly can lead to Scientists must consider the time course misleading results. of disease progression. For instance, if a sample A further complication is that when one begins at age 60 and beyond, substantial examines the predictive power of SWB at Time cardiovascular damage is likely to already have 1 on later longevity, it must be recognized that occurred in many participants. Thus, if not only are the Time 1 measures a snapshot at researchers control for Time 1 health they may that time that does not capture SWB during all inadvertently over-control in the sense that they the prior years, and which could have affected eliminate possible detrimental effects of low health during those years, but also that SWB SWB that might have occurred over many might change after Time 1. Fujita and Diener decades, and might also control away future (2005) found that a significant number of damaging effects of low SWB because these individuals change substantially in well-being will be highly related to the rate of damage that over a period of years. Thus, Time 1 SWB has already occurred. When we control Time 1 might not fully predict longevity in part because health we jettison potential earlier effects of it rose or declined over time, and also a measure SWB on health from our analysis. Not only that, at one point in time does not fully capture the but we diminish the likelihood of uncovering long-term effects. Thus, highly reliable further effects of SWB that continue at the same measures and ones that occur over time will be rate as before. By controlling Time 1 health we needed to fully capture SWB's effects on health. essentially now examine whether the rate of When mediocre measures of SWB are employed SWB's influence on health is changing after that at one point in time, they cannot be expected to point in time, not whether the level of SWB is fully assess the influences that might be influencing health. In controlling Time 1 health occurring. we thereafter will only uncover effects when they occur at a greater rate than previously. We Controlling Potential Confounds have altered the question the statistics answer from whether SWB can influence health, to Concerns about statistical overcontrol whether it does so at a different rate than it did in behavioral research have been expressed previously. The fact that so many studies have by others (e.g., Spector, Zapf, Chen, & Frese, shown positive results even after controlling 2000) because of the possibility of throwing Time 1 health might mean that the effects of out phenomena by inadvertently erasing SWB on health do increase with age. their effects. However, in the fields both of The current standard practice of control SWB and health these concerns have not might be more informative for diseases that received widespread attention. occur quickly without prior conditions that point Researchers must fully understand the to them. In this case, controlling health at Time conceptual and statistical implications of the 1 may make sense. In this case the course of controls they use. It is not that controls should illness is abrupt and discontinuous, and never be employed, but they must be therefore controlling for T1 health does not implemented cautiously, and their limitations throw out all the earlier influences of SWB. fully appreciated. In light of the strong effects However, for many diseases there is a statistical controls can exert, and their ability to progression of the condition over many years, over-control away true associations, it is even decades. The condition might only become remarkable how frequently significant effects fully evident and full-blown at some point in have nonetheless been uncovered. time, but the physiological conditions underlying it might have progressed throughout Psychological Well-Being and Health 18

Caution alone is not enough to wisely regression analyses are reported, it is impossible use statistical controls. For instance, we can for readers to fully understand the associations employ methods when we control variables that between the variables. take measurement error into account. We can be Third, investigators can employ certain that we know the variables employed are alternative strategies and methods that take in fact likely to be confounds. For instance, if potential confounds into account and possibly we control various types of maladies at Time 1 control them, but in meaningful ways. For because they might be confounds by influencing example, one can obtain reports of SWB at an SWB, we should know that in fact these early age, and then not examine mortality until conditions do influence people's well-being. many years later. This greatly reduces the risk Without such knowledge the risk of over-control that Time 1 health was a confound because it easily outweighs the risk of confounding. For had been influencing SWB. If the sample is not example, in the Liu et al. (2016) study described tracked until some duration after the Time 1 earlier, the investigators should have determined SWB measures were obtained, it is less likely whether hypertension and diabetes affect SWB that health had much effect on SWB at that before controlling them as possible confounds. time. For instance, in the well-known nun study Similarly, researchers should understand how by Danner, Snowden, and Friesen (1998), the objective health differs from subjective reports autobiographies on which the SWB scores were of health, so they know how much potential estimated were collected around age 22, and the variance in SWB might be erased by controlling nuns' mortality was not tracked until after they the subjective reports versus simply controlling reached 75. Thus, it is unlikely that health had objective health measures. much effect on the early assessment of SWB Statistical controls represent a theoretical because the nuns in the study all lived for 50 or statement about the structure of the dynamic more years beyond that time before the tracking system, and are not simply a way of removing began. Similarly, Steptoe (2016) assessed confounding variables. It may be that in fact enjoyment of life, but did not begin tracking using statistical controls does not distort mortality in the sample until two years beyond findings in particular cases, and does help when the initial measures of SWB were control confounding variables. However, this collected. In the ensuing eight years he found happy circumstance cannot be assumed without one-third the mortality in the highest compared understanding and carefully analyzing each of to lowest enjoyment of life group. In this way the associations between all of the variables Steptoe lowered the likelihood that Time 1 used in the analyses. health was not exerting a profound effect on We suggest that statistical controls can SWB at Time 1 because his sample did not be more problematic and challenging than most include those who died in close proximity to the researchers have realized. They do not measure of well-being. magically solve the problem of confounding Another way of controlling possible variables. What is a researcher to do in this case, confounding variables is to examine data that when confounding variables obviously often are experimental or quasi-experimental in may represent a problem? First, statistical nature. For example, one can examine whether controls should be presented and interpreted physiological and health measures are carefully. Not only should the simple zero-order influenced by experiments designed to raise correlations among all variables be presented in people's SWB. One can examine whether all research reports, but controls should be stressful events that cannot be attributed to the entered in a way that allows examination of subjects' individual characteristics, such as war each of their separate influences. In this way, or an earthquake, affect people's SWB and in readers can gain a clearer picture of the turn their health. People whose SWB is raised associations involved. When only final by a random event such as winning the lottery Psychological Well-Being and Health 19 could be examined in terms of their health by SWB and health, as well as potential thereafter. confounding variables. Both direct and indirect Researchers also have controlled for pathways by which SWB can influence health certain confounding variables by studying twins, must be specified. Although it is never possible and employing statistical controls. Genetic to assess all the potential confounding variables, studies that utilize the identical chromosomal the major ones need to be identified. For an makeup of twins can help rule out genes as the introduction to causal modeling, readers are sole cause of the health and SWB relationship. referred to sources such as Imbens and Rubin Sadler et al. (2011), for example, found that (2015) and Mayer et al. (2014). SWB was related to increased longevity in An important ingredient for strong identical twins. Because SWB predicted causal modeling is that the important variables longevity even between identical twins, the in the model are assessed repeatedly over time. results indicated that the relation between SWB For example, to determine the causal direction and longevity cannot entirely be due to either between SWB, health behaviors, and health genes or shared family environment. Animal outcomes, at a minimum the researcher should research is another way to overcome the have a measure of SWB at T1, a measure of potential confounds that often occur in studies health behavior somewhat later, and a measure on humans. of health at T3 following that. Furthermore, if each of the variables is assessed repeatedly at Causal System Modelling each of the time points, it allows not only predictions from the levels of each variable, but An additional method for exploring also from their change over time. Ideally of complex systems is causal modeling, which is a course this will include multiple points in time, statistical approach in which the empirical data not just three. are fit to a model of interconnected variables, We know of no studies that have and the goodness of fit can be judged. examined full causal models in which the Improvements to the fit of the model can be pathways going from SWB to the mediators and calculated when paths of direct and indirect to health outcomes, as well as possible influence are added or eliminated. Alternative confounds (that might also cause or be plausible causal models can be tested against influenced by SWB), have been tested one another. When data are longitudinal, causal simultaneously in the same specified model. direction can be explored by comparing the fit Furthermore, we know of no studies that of models that move in either direction over simultaneously measure factors beyond SWB, time. In this way, factors such as income that such as social support, that are thought to might be potential confounds, but also might influence health but also influence and can be result in part from SWB, can be included and influenced by SWB, so that the direct and yet not simply controlled away in a fashion indirect effects of them in combination with likely to spuriously introduce errors of SWB can be assessed. For example, does social inference. One feature of causal modeling is that support influence health because it raises well- it can employ multiple measures of variables being and lowers stress, or does SWB influence and analyze the data using Structural Equation health because it makes people more sociable? Modelling, in which case the effects of Causal parsing also has not been measurement error can be assessed and conducted with a broad set of SWB variables obviated. simultaneously, including optimism, life To adequately conduct strong causal satisfaction, stress, and enjoyment of life, for modeling a conceptual framework is needed that example, with large samples to determine the posits relationships between each of key common and unique effects of these well-being variables that can influence and be influenced variables on health. Although positive and Psychological Well-Being and Health 20 negative affect have been shown to have unique negative emotions such as stress and depression, associations with health, an assortment of types but positive emotions as well. A few studies of SWB have not been carefully separated using include life satisfaction, optimism, and other sufficiently large samples. To strongly related variables as predictors as well. Because determine the separate effects of various forms these measures are inexpensive and quick to of SWB, analyses are required that include include, they should be employed more corrections for measurement error. Causal frequently. We know that positive and negative modelling with longitudinal data, as well as emotions appear to have separable effects, but experimentation in which the causal factors are we know little about the differential effects of each varied, are needed to help understand the other types of SWB. However, because these full causal system going from psychological and variables tend to correlate, sometimes social variables to health. substantially, very large samples are needed to Needed Research reliably pinpoint their unique effects. We began the review by asking whether Research is also needed on the measures SWB influences health and longevity. In light of being employed. Different measures may tap the review we can now give greater focus to this different aspects of the underlying concept, and question. We now know with some degree of therefore produce results that could differ from confidence that SWB can influence health- other measures of supposedly the same variable. relevant biological indicators, health, and For instance, the widely used PANAS (Watson, longevity, at least in some instances. We have Clark, & Tellegen, 1988) scale of positive and strong leads on several explanations of how negative affect focuses on the experience of SWB affects health. We also know that SWB is highly activated and intense emotions (e.g., neither a necessary nor sufficient cause of health excited and enthusiastic). Other scales often because other factors clearly influence health, assess less aroused forms of positive emotion and even in the absence of high SWB some such as happiness or contentment (Diener et al., individuals are healthy. A major unanswered 2010). It is possible that positive emotions are question now is when SWB does and does not generally beneficial to health, but highly influence health. Much more research is needed, aroused ones may be detrimental (e.g., but certain areas seem to be particularly Pressman & Cohen, 2005). Therefore, measures understudied. of positive affect should not be assumed to be 1. We need much more moderator identical. Positive feelings have been assessed research in which the factors that alter the by cheerfulness and sense of humor, and by the relationships between SWB and health are enjoyment of life and other measures as well. studied. As it now stands we have inconsistent There may be overlapping influence between findings, for example that SWB is related to a many of these concepts but we cannot be certain health outcome for one sex, but not for the until this is tested. It could also be that some of other. Furthermore, these moderators sometimes these measures capture more activated and reverse from one study to the next. We have aroused feelings, whereas others capture calm little understanding of these findings, and many and contented feelings, and the two might have other potential moderators remain unstudied. distinctly different effects on health. This area demands much more in-depth study Furthermore, one-time global self-reports of and theoretical development. SWB might differ from well-being captured by 2. Research is needed that examines the experience sampling measures or informant common and unique influences of the various reports of SWB. forms of high and low SWB, for example, life The level of SWB that most benefits satisfaction, positive affect, optimism, and health deserves more extensive study. Are there stress. Many but not all researchers now threshold effects, above which SWB no longer recognize the importance of assessing not just benefits health? Are there levels of SWB such Psychological Well-Being and Health 21 as highly aroused positive affect that can harm 6. Much more research is needed to health, and how might they do so? parse the interacting effects of variables such as 3. The time course of various health income and social relationship quality, which outcomes is also important to consider in terms can be influenced by SWB but also influence of the influences of SWB. Some outcomes SWB. Exploring these variables together with might slowly accumulate over many years, such SWB is needed to understand whether they as the buildup of arterial plaque. Other directly influence health, or do so by influencing outcomes, such as stress-induced tachycardia SWB, which in this case is the mediator. There might be immediate, and yet depend to some are a large number of variables that can degree on earlier unhealthy developments over influence health, but which co-occur with SWB. decades. Similarly, some causes of health or Sleep is a prime example. It can influence health illness occur over long periods of time, for and SWB, but SWB can also influence it. Thus, example the effects of health behaviors such as sophisticated designs are needed to disentangle using sunscreen and healthy nutrition. Other its effects separately from the effects of SWB, outcomes may depend on immediate mood, yet and this is true of other variables such as in combination with physiological patterns in income. the person that have been laid down over a long 7. More nonhuman animal research will period of time. Sorting out these differences be informative, especially on the effects of well- both theoretically and empirically should be a being on health. A number of studies on animals goal of future research, requiring that measures have examined the influence of stress on health, be administered repeatedly over time. but few have examined whether felicitous 4. More experimental research is needed circumstances that would be thought to induce on interventions in which long-term positive positive feelings influence animal health. One psychological states are raised and the effects on reason that animal research adds to experiments health assessed, including in populations who and other research with humans is that are not suffering from ill-being. The long-term conditions can be more fully controlled with experiments are particularly valuable in animals, and certain third-variable explanations establishing the causal impact of SWB on ruled out. In addition, the interactions of health. Even in the realm of treatments to genetics and SWB can be studied. Fortunately, reverse states of ill-being such as depression and there has recently been increased interest in anxiety much research is needed. Studies in assessing the emotions of animals, and these which well-being is raised in normal methods may prove useful in the SWB and populations will help shed light on optimal health domain. levels of well-being. 8. In terms of assessing SWB, it would 5. Third-variables such as prenatal be desirable to move beyond one-time self- effects and childhood environmental effects report survey measures in assessing SWB. Not need to be examined in terms of whether they only would it provide more reliable measures if are, at least in part, responsible for the SWB and SWB were to be assessed at several points in health associations that have been found. Could time, but it would also be potentially helpful to it be that the early environment, including add other types of measures beyond simple self- factors such as prenatal nutrition and stressful report surveys. Brain location methods, early family conditions, can influence both later experience-sampling, as well as approaches SWB and health through the adult lifespan? If such as informant estimates of the SWB of the so, how much do these effects explain the SWB target respondent, memory and reaction-time and health connection? Although some variables cognitive measures, facial and nonverbal such as SES have been studied frequently and expression measures, and assessments of controlled, other possible explanatory third emotional expressivity skills would be helpful to variables remain understudied. add to our research armamentarium. The Psychological Well-Being and Health 22 advantage of multiple assessment methods for evidence base is not beyond a reasonable doubt, measuring SWB is based on the premise that the preponderance of evidence suggests that at none of them are perfect, and each contains least some individuals would benefit from some error of measurement. Thus, using latent having higher SWB. Current evidence also traits of combined measures could produce more suggests that in routine medical check-ups valid measures. Furthermore, concerns with screening not only for negative emotional states, self-report measures such as their confounding but also for low positive ones, might be helpful. overlap with other measures can be reduced by Furthermore, interventions are now being tested including nonself-report measurement methods. that may raise well-being in much less costly 9. More causal modeling of multiple ways than traditional individual psychotherapy. influences on health needs to be conducted, in However, the evidence base at this point is too which direct and indirect pathways from SWB sparse to strongly recommend that assessments to health are analyzed. Factors that may or interventions for high SWB become routine influence SWB and/or health should be included parts of healthcare practice. Further, there are in these analyses to more carefully parse their complicating factors that must be explored such effects. Because of the simpler statistical as the potential detrimental effects of high- approaches that have characterized the field, arousal positive affect. many existing data sets could be revisited with For research scientists, the field is wide more sophisticated analyses. open for needed advances with applied 10. If we can uncover the process by implications. When does SWB influence health, which brain states are related to emotions and and when will increases in well-being further feelings of well-being influence the endocrine, benefit health? Are there physiological and immune, and cardiovascular systems, it might behavioral patterns evident in happy individuals be possible to mimic those states that we could raise in a direct way even when physiologically in people who are not readily increasing SWB might be difficult or costly? responsive to well-being interventions. 11. Cultural differences in the SWB and Summary and Discussion health connection are wide open for research. The few studies conducted to date suggest that To the question of whether SWB can there may be differences in the effects of certain influence health, at least in some instances, we emotions on health, depending on cultural answer in the affirmative with some degree of context. certainty. To the question of how this occurs, we now have initial answers, for example, in terms Applied Versus Theoretical Issues of the of health behaviors, and the immune and Research cardiovascular systems. To the question of when this occurs and when it does not, and where it is The question of when and how SWB most likely to occur, we as yet have only affects health is of both theoretical and applied scattered initial hypotheses, and this is one of importance. For healthcare practitioners the the big directions for future research. To the evidence now seems sufficient that in some question of how large the effects are we have cases they may be concerned about the SWB of some initial estimates from scattered studies, for their patients. Naturally, when patients suffer example in terms of extra years of life and odds- from problems such as depression or anxiety ratios, but to our knowledge no systematic disorders, a referral for proper treatment is reviews and analyses have been conducted. advised. However, with certain disease groups How do the effects of high versus low SWB such as cardiovascular disease, interventions to compare, for example, to the beneficial effects raise the well-being of clients and reduce their of exercise or not smoking? stress now seem justified. Although our Psychological Well-Being and Health 23

We know little yet about whether Our review suggests that encouraging interventions to directly raise well-being will progress has been made in our scientific improve health and longevity. The results of understanding of the well-being influence on such studies so far have been mixed, perhaps in health, but many important and intriguing part due to the difficulty of raising long-term research questions remain. The reviews makes SWB in a nontrivial way. We do not know if clear that we need to know more than the simple there are threshold effects beyond which experimental question framed as to whether increases in SWB do not have benefits. Finally, SWB has a causal influence on health. We are there are potential third-variable explanations of now moving beyond the initial stages of the effects, for example prenatal nutrition, that research in this area where exciting associations have not yet been ruled out. Thus, we have have been uncovered, to more sophisticated some answers to various aspects of SWB approaches that can identify the full set of causing health outcomes, but there is much conditions when SWB will affect health and more to learn. when interventions to increase SWB will improve health.

Acknowledgements

We are grateful to the AXA Research Fund for their partial support of this paper, as well as to scholars who gave us recommendations about this paper: Michael Eid, Louis Tay, and Richard E. Lucas.

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APPENDIX Tables 1 – 9 and Supporting References

Table 1 Reviews of the SWB and Health Literature

Meta-Analytic Reviews

Reference Findings

Bolier et al. (2013) A meta-analysis of positive psychological interventions, which included self-help training, group training and individual therapy. They found that the interventions produced small but significant effects on mental health for up to three to six months. Chida & Steptoe (2008) Sixty studies were reviewed of both healthy and ill samples, with positive affect, optimism, and life satisfaction being predictive of increased survival. Faragher, Cass, & Cooper Found across 485 studies that job satisfaction was (2005) associated with subjective health. Grossman, Niemann, Schmidt, Meta-analyzed studies meeting the criteria for & Walach (2004) methodological rigor and found that mindfulness-based interventions significantly increased reports of both physical and mental health. Howell, Kern, & Lyubomirsky Experimental, ambulatory, and longitudinal studies were (2007) reviewed (N = 150). For short-term outcomes, the authors found that SWB was most strongly associated with immune functioning and pain, less strongly associated with endocrine response, and not associated with cardiovascular reactivity. For long-term outcomes, SWB was strongly associated with both cardiovascular health and longevity. SWB was also associated with disease progression and survival. Lamers, Bolier, Westerhof, In 17 studies, the researchers found a small but significant Smit, & Bohlmeijer (2012) protective effect of emotional well-being for recovery and survival in physically ill patients. Lyubomirsky, King, & Diener Reviewed over 40 short-term and long-term longitudinal (2005) studies, and concluded that high SWB predicts future health and survival, with only one study showing the opposite effect. Cross-sectional and experimental studies were also supportive of a relationship between happiness and health. Experimental studies primarily found influences of SWB on pain, as well as immune and cardiovascular functioning. Psychological Well-Being and Health 28

Okun, Stock, Haring, & Witter In a meta-analysis of a large number of studies, SWB was (1984) associated with health outcomes, including after statistical control variables were applied. Rasmussen, Scheier, & Optimism was found to be predictive of mortality, as well Greenhouse (2008) as with a host of specific illnesses and physiological markers of health. Roepke et al. (2014) A systematic review of the association of meaning in life and health Roest et al. (2010) A meta-analysis of twenty studies concluded that anxious individuals are at a greater risk of coronary heart disease. Rugulies (2002) Found in a meta-analysis that depression is predictive of coronary heart disease. Steptoe & Kivimaki (2013) Stress found to be strongly related to cardiovascular disease.

Traditional Literature Reviews

Boehm & Kubzansky (2012). Lowered risk of cardiovascular disease was best predicted by optimism. The authors also found that cardiovascular health is more consistently associated with optimism and hedonic well-being than with eudaimonic well-being, although the numbers of studies on the latter was quite limited. Broadbent & Koschwanez Reviewed evidence indicating that people higher in positive (2012) affect show quicker wound healing after stress than do those lower in positive affect. Carver, Scheier, & Segerstrom Reviewed the extensive literature relating optimism to (2010) health and pessimism to ill-health. Diener & Chan (2011) In 25 of 26 studies various forms of SWB, especially positive feelings and optimism, predicted longevity and mortality, although in a few of the studies those predictions held for only one group, for example, for men only. DuBois et al. (2012) Reviewed the potential mechanisms by which psychological well-being can influence cardiac outcomes. Marsland, Pressman, & Cohen Reviewed studies using various methodologies that suggest (2007) that positive affect upregulates the immune system. Mood induction studies suggest that perhaps affect arousal of either valence upregulates the immune system, whereas naturalistic studies tend to show an association between positive affect and immune strength. Pressman & Cohen (2005) Trait positive affect is associated with longevity, as well as lower morbidity and pain. Short-term inductions of highly aroused positive affect can produce potentially unhealthy changes in physiology, whereas long-term ambulatory positive affect is often associated with beneficial physiological patterns. Rozanski & Kubzansky (2005) Review evidence showing that chronic stress is related to cardiovascular disease, and positive states tend to be Psychological Well-Being and Health 29

associated with fewer cardiovascular problems. Sin (2016) The review found that positive well-being is related to better cardiovascular health and lower incidence of heart disease in healthy populations, and with reduced risk in patients with heart disease. Psychological Well-Being and Health 30

Table 2 Correlational Studies of the SWB and Health Association

Citations Findings

Blanchflower & Oswald In 16 European nations found an association of mean happiness (2008) reports and self-reported high blood pressure. Chopik & O'Brien Having a happy partner was found to be associated with better (2016) health, beyond the effects of one's own happiness. Cohen & Rodriquez A theoretical rationale and supportive evidence is reviewed that (1995) physical and mental disorders are associated in a bidirectional fashion. Ladwig et al. (2003) In obese, but not nonobese, subjects there was an association between depression and C-reactive proteins. Lambiase et al. (2015) Emotional vitality (including energy, emotion regulation, and positive well-being) was associated in a dose-response manner to lower levels of cardiovascular disease. Lawless & Lucas (2011) Across USA counties those with higher mean life satisfaction had higher objective health indicators. Licht et al. (2008) Depression is associated with lower heart rate variability, although this might be primarily driven by antidepressant medications. Liu et al. (2014) Very old individuals, 95 and older, in China were found to have high levels of positive affect and life satisfaction, and low negative affect. Mojon-Azzi & Sousa- European nations with low average life satisfaction had higher Poza (2011) mean blood pressure. Pressman et al. (2013) An association was found between positive affect and reported health in 142 diverse nations, with the correlation between strongest in economically less developed nations. Steptoe et al. (2012c) Found that anemia is associated with greater levels of depression Steptoe et al. (2009) Independently of negative affect, positive affect was associated with beneficial cardiovascular and immune markers, adjusting for health and SES. Taylor et al. (1993) Elevated cortisol levels were observed after childbirth in women with the "blues," but lower levels in women with hypomania. Valdimarsdottir Both positive mood and low negative mood were associated with &Boybjerg (1997) more natural killer-cell activity, but positive mood only showed an association for those with some negative moods that day. Psychological Well-Being and Health 31

Table 3 Longitudinal Studies of SWB and Health Outcomes

Citations Longitudinal Findings

Carrico & Positive affect did not directly predict lower viral load in HIV positive Moskowitz (2014) men, but an indirect effect through persistence with anti-retroviral therapy. Danner, Snowden, & Estimates of nun's happiness taken from a time when they were about Friesen (2001) 22 years old predicted longevity in a study that followed survival starting about age 75. Because the nuns lived in similar circumstances, certain third-variable explanations can be ruled out. Fisher & Sousa-Poza Job satisfaction predicted fewer doctor visits, less sick leave, and fewer (2009) accidents on the job. Gale et al. (2014) Both hedonic and eudaimonic well-being predicted frailty over four years, controlling for several possible confounding covariates. Ickovics et al. (2006) Positive affect predicted lower mortality over the ensuing five years in people with HIV, controlling for initial SES, viral load, antiretroviral therapy, and depression. Kim et al. (2014a) In adults 50 and older having an optimistic spouse was predictive of better physical functioning and fewer chronic illnesses. Kim et al. (2011) Optimistic oldsters had fewer strokes, controlling for many factors. Kim et al. (2014b) Over four years those initially high in life satisfaction had fewer doctor visits, controlling for SES, baseline health, and psychosocial factors. Moskowitz (2003) Positive affect in HIV infected men predicted lower risk of AIDS and mortality over periods up to 7.5 years, control for medications and the extent of the initial infection. Ostir et al. (2000) Positive affect at baseline had a large predictive effect on mobility, functional status, and survival two years later, controlling for functional status, SES, major chronic conditions, BMI, smoking and drinking, and negative affect at baseline. Pressman & Cohen Positive affect estimated from the autobiographies of eminent 2012 psychologists predicted their longevity. Ryff et al. (2015) Found that those who were persistently high in SWB over time had better subjective health, fewer symptoms, chronic conditions, and functional impairments. Seale et al. (2010) Among those discharged from rehabilitation therapy, improvements in positive emotions predicted functional, motor, and cognitive status at three-month follow-up. Steptoe et al. (2012a) Enjoyment of life was predictive of later disability, gait speed, and incidence of death. Life satisfaction was weakly predictive of mortality, and low affective well-being predicted cardiovascular disease. Steptoe et al. (2014) At an eight-year follow-up original enjoyment of life predicted functional status, such as functional status, controlling for various potential confounds. Steptoe & Wardle Positive affect was recorded over the course of a day and the scores Psychological Well-Being and Health 32

(2011) predicted survival at five year follow-up, in adults aged 52 to 79. Voellmin et al. (2013) Higher SWB lowered the risk of preterm delivery. Xu and Roberts High SWB was predictive of longevity in a large sample, controlling (2010) many factors such as baseline health, age, and marital status. Yanek et al. (2013) Positive well-being strongly predicted less cardiovascular diseases in a high-risk but initially healthy group, controlling for demographics and traditional risk factors. Psychological Well-Being and Health 33

Table 4 Experiments That Aim to Raise Long-Term SWB and Examine Health

Citations Findings

Andersen et al. (2004) A multi-pronged psychological intervention including both improving mood and stress reduction in cancer treatment patients led to better health behaviors such as reduced smoking, and to improvement or stability in immune parameters that tracked the psychological improvements (compared to the control group who showed declines). Berkman et al. (2003) A psychosocial intervention produced small but significant reductions in depression in myocardial infarction patients, but no greater survival. Blumenthal et al. Compared to cardiac rehabilitation alone, those also receiving stress (2016) management training had lower rates of stress and clinical events. Charlson et al. (2014) In a sample of individuals with chronic cardiopulmonary disease, compared to education-only controls, those who also received a positive affect intervention showed greater positive behavior change. The change was evident in patients who encountered negative psychosocial changes and negative events. Davidson et al. (2003) Mindfulness mediation training increased left-frontal brain activation, which is associated with positive affect, and increased antibodies to influenza compared to the control group. Frasure-Smith & Prince A home-based stress reduction treatment compared to controls in male (1985) myocardial infarction patients led to reduced stress and a nearly 50% reduction in deaths. Myocardial infarction in the next seven years was also lower. Gulliksson et al. (2011) Experiment comparing the standard treatment for coronary artery disease versus the standard plus cognitive behavioral therapy for stress reduction found substantial benefits over eight years for recurrent cardiovascular events and myocardial infarctions, and a nonsignificant but 28% reduction in mortality, with a strong dose-response association. Linden, Phillips, & A meta-analysis of intervention experiments showed that Leclerc (2007) psychological treatments reduced all-cause mortality at 2-year follow- up for men but not for women, and weakened with longer follow-up. The mortality benefits occurred despite only small decreases in negative affect. Miller & Cohen (2001) In a meta-analysis of 95 studies it was found that hypnosis and conditioning were the most consistent predictors of immune changes, disclosure and stress management occasionally produced changes, and relaxation did not modulate immune parameters. Ogedegbe et al. (2013) Small gifts and self-affirmation exercises to raise positive moods led to better medication adherence. O'Neil et al. (2011) Reviewed five randomized controlled trials and found that treatment for depression improved mental health, and modestly but significantly improved physical health. Psychological Well-Being and Health 34

Orth-Gomer et al. Psychosocial and stress reduction in female cardiac patients led to (2009) one-third fewer death in 7-year follow-up period. Nikrahan et al. (2016) One of three positive psychology interventions was given to cardiac patients and it was found that two reduced inflammation and one reduced waking cortisol levels. Peterson et al. (2012) Coronary care patients who had a percutaneous coronary intervention were compared in a 12-month rehabilitation follow-up to a standardized exercise education intervention, and received self- affirmation and positive affect education, bimonthly positive affect telephone calls, and periodic small gifts. Calorie usage indicated a significant and doubling use of kilocalories in the positive intervention group, and change in physical activity was predicted by changes in affective well-being. Rutledge, Redwine, Found across 36 studies that psychological interventions moderately Linke, & Mills (2013) reduced the number of future cardiac events and symptoms of depression, but not mortality. Stanton et al. (2002) In an experimental design, women undergoing cancer treatment who did either emotion writing or positive writing about the experience had fewer appointments for cancer-related morbidities compared to controls. Thombs et al. (2013) Treatment for depression in cardiovascular patients with psychotherapy or medications produced modest reductions in symptoms, but the treatments did not improve cardiac outcomes. Whalley et al. (2011) In a review of studies, psychological interventions only modestly reduced cardiac mortality and depression among patients with CHD. Interventions aimed to treat type-A behavior decreased depression. However, education about risk factors, discussion groups, discussion groups focused on emotional support, and family member involvement were ineffective. Psychological Well-Being and Health 35

Table 5 SWB and Cardiovascular Indicators of Health

Citations Studies of SWB and Moods Influencing Cardiovascular Functioning

Bacon et al. (2004) Cardiac patients’ anger, stress, and sadness were all associated with lower cardiac functioning as assessed by 48 hours of ambulatory electrocardiography, and positive emotions with increased low frequency activity. Bhattacharyya & Monitored coronary artery disease patients over time and found that Steptoe (2011) negative moods preceded cardiac dysfunction in the 15 minutes before the episode. Blascovich & Tomaka Reviewed evidence showing that stress raises heart rate and blood (1996) pressure, where a challenge does not because arterial dilation counteracts the effects of increased heart rate. Bhattacharyya et al. Healthy heart rate variability was predicted by positive feelings. (1979) Boehm et al. (2001) Both men and women without previous cardiovascular events and who were higher in well-being, including emotional vitality and optimism, and had less cardiovascular disease over a five year follow-up. Boehm et al. (2013) Optimistic individuals had greater levels of high-density cholesterol and lower levels of triglycerides. Daly et al. (2010) Daily elevated ambulatory heart rate within participants was associated with negative affect. Dockray & Steptoe Reviewed evidence showing that positive affect separately from (2010) negative affect predicted cardiovascular functions such as blood pressure. Eichstaedt et al. (2015) Analysis of Twitter communications showed that counties of the USA high in the expression of positive emotions and low in the expression of negative emotions, especially anger, were more likely to experience lower heart disease mortality. The predictions from Twitter produced larger effects that 10 other predictors combined, including demographic, socioeconomic, and health risk factors such as smoking, diabetes, hypertension, and obesity. Freak-Poli et al. Positive affect was not predictive of cardiovascular disease over time in (2015) a large sample in the Netherlands. Fredrickson et al. When participants were exposed to an anxiety-inducing treatment, (2000) those who then saw an amusing or contentment-inducing film showed quicker cardiovascular recovery. Gullette et al. (1997) The percentage of ischemic (restricted blood supply) hours was higher during negative emotions and lower during positive emotions. The relative risk for ischemic events was much higher during negative moods (e.g., tension, sadness, and frustration). Howell, Kern, & Review of research showed that SWB is related to blood pressure and Lyubomirsky (2007) other indicators, with these effects being somewhat stronger in Psychological Well-Being and Health 36

experimental studies. Ilies, Dimotakis, and Negative affect was correlated significantly with blood pressure across Watson (2010) time within individuals. Kok et al. (2013) An intervention experiment in which positive emotions were raised through loving-kindness meditation led to increased vagal tone. Kraft & Pressman Induced smiling in an experiment led to quicker heart rate recovery (2012) after stress inductions. Matchim et al. (2011) A mindfulness intervention reduced heart rate, blood pressure, and respiratory rate, but lower waking cortisol was not sustained over time. Ostir et al. (2006) Positive emotions were related to lower levels of both types of blood pressure for people not on hypertensive medications, but only to lower diastolic blood pressure for those on these medications. Pollard & Schwarz Over time changes in tense arousal were associated with changes in (2003) systolic and diastolic BP, and increasing negative valence of emotions was associated with systolic BP. Pollock et al. (1979) Natural mood states such as depression and tension were correlated with heart rate and blood pressure in the predicted directions. Provost & Gouin- Inducing anger and distress in infants increased their heart rate, but the Dicarie (1970) positive affect induction had a small and nonsignificant influence. Shapiro, Jamner, & Sad feelings and low positive feelings were associated with diastolic Goldstein (1997) blood pressure during sleep, but trait hostility and other negative moods were consistently related to higher blood pressure, but particularly during sleep. Shapiro et al. (2001) Increasing negative moods were related to increasing heart rate and blood pressure in nurses. Steptoe, Demakakos et SWB was associated with lower triglycerides and better lung function al. (2012b) in both men and women. Steptoe, Wardle, & Positive affect was associated with lower heart rate and lower levels of Marmot (2005) fibrinogen. Tuck et al. (2017) Greater ability to express positive emotions was associated with lower risk for cardiovascular disease. Tugade & Fredrickson The negative impact on cardiovascular function of a negative affect (2004) induction was countered by a positive affect induction that caused participants to more quickly return to baseline.

Examples of Studies Showing that Cardiovascular Indicators are Associated with Health

Gruenewald et al. The researchers found that most biomarkers they assessed predicted (2006) mortality over 12 years, but that systolic blood pressure was the most frequent predictor for women and immune and neuroendocrine parameters were frequent predictors for men. Kannel et al. (1987) Higher heart rates are associated with higher mortality. Welin et al. (1987) High systolic and diastolic blood pressure, and levels of plasma fibrinogen are each related to greater incidence of stroke. Psychological Well-Being and Health 37

Table 6 SWB and Immune Indicators of Health

Citations Findings Relating SWB to Immune Function

Barak (2006) A review of studies showing that positive affect as well as eudaimonic well- being are related to stronger immune function. Ben-Shaanan et Designer drugs were used to activate a part of the reward system of the al. (2016) brain (ventral tegmental area) of rodents, which produced a stronger immune response (T-cells, monocytes, and macrophages) and a lower in vivo bacterial load after an infection of Escherichia coli was introduced. Ablation of the sympathetic nervous system suggested that the causal effects of reward stimulation on immunity were at least in part mediated by the SNS. Boehm, Vie, & Life satisfaction and emotional vitality were related over time (statistically Kubzansky (2012) controlling for demographics) with the odds of doctor-diagnosed diabetes, but optimism was not predictive. None of the well-being variables predicted incidence of screen-detected diabetes. Brouwers et al. In cardiac patients, positive affect was at three time points associated with (2013) lower levels of several inflammatory markers, adjusting for clinical and lifestyle confounders. Cohen et al. Positive emotional style was related in a dose-response manner to lower risk (2003) of developing a cold after being infected, controlling for the pre-infection virus-specific antibody, whereas negative emotionality was not. Cohen et al. (2006) replicated this finding, controlling for optimism, mastery, and self- esteem, as well as self-reported health. Denson et al. Reviewed 66 experiments in which affective states were induced. Cognitive (2009) appraisals, basic emotions, rumination and worry, and social threat influenced cortisol and immune parameters as expected, but global mood states were unassociated with effect sizes. Dillon, Viewing a humorous film raised salivary immunoglobulin. Minchkoff, & Baker (1986) Doyle, Gentile, & Positive affect predicted lower subjective and objective markers of illness in Cohen (2005) those exposed to rhinoviruses, and this association was decreased substantially when IL-6 was controlled. Futterman et al. Mood inductions of positive affect influenced a variety of immune (1994) parameters. Hamer & Chida Life satisfaction predicted lower levels of fibrinogen and C-reactive protein (2011) after adjusting for demographics, depressive symptoms, smoking, and BMI. Hucklebridge et Inductions of both positive and negative mood upregulated sIgA. al. (2000) Ickoviks et al. Optimism, positive affect, and meaning in life were all related to less (2006) decline in CD4 cells in individuals infected with HIV. Lambert & Watching a humorous film was associated with higher sIgA. Lambert (1995) Psychological Well-Being and Health 38

Levy & Bavishi Although positive views of aging did not directly predict survival, a (2016) mediational path to survival was found through levels of C-reactive protein. Marsland, Reviewed ambulatory change studies of trait positive affect and Pressman, & experimental studies that reveal that positive emotional states are related to Cohen (2006) stronger immune function. Njus et al. (1996) A positive writing mood induction led to higher levels of SigA. Prather et al. Trait positive affect was inversely associated with certain inflammatory (2006) markers, although in some cases only in men and not with all markers. Smith et al. Trait hostility associated with inflammatory markers not only in the person, (2014) but in their partner as well. Stellar et al. Positive emotions such as awe were inversely associated with inflammatory (2015) cytokines. Steptoe et al. Actors portraying both positive and negative emotions raised inflammatory (2007) markers, regardless of valence. Suarez et al. Reviews evidence showing that negative emotional states are associated (2004) with inflammatory markers. Uchino et al. High life satisfaction was associated with lower inflammatory markers. (2017)

Examples of Immune System Dysregulation Associated with Poor Health

Cesari et al. (2003) Several cytokines were associated with cardiovascular disease. Kiecolt-Glaser et Reviews findings showing that immune dysregulation is associated with a al. (2002) host of health problems, ranging from cardiovascular disease to arthritis to slow wound healing. Singh & Newman In a literature review it was found that Interleukin-6 is related to disability, (2011) disease, and mortality in the elderly. Wellen & Reviews evidence showing that inflammation is related to diabetes and Hotamisligil obesity. (2005) Psychological Well-Being and Health 39

Table 7 SWB and Healthy Behavior

Citations Findings Relating SWB to Healthy Behaviors

Baruth et al. (2011) Emotional outlook predicted increased physical activity in inactive men. Boehm & Kubzansky Reviewed evidence showing that SWB states such as optimism are (2012) associated with both better health behaviors and physiological patterns. Boehm, Vie, & Happy people are more likely to do healthy behaviors such as Kubzansky (2012) exercising and not smoking. Carver et al. (2010) Optimism was related to more health behaviors. Emmons & A gratitude intervention over 9 weeks led to more physical exercise McCullough (2003) and fewer illness symptoms during that period. Friedman & Ryff Life satisfaction, positive affect, and negative affect were all related to (2012) body mass index and smoking in the expected directions, but exercise frequency was not significantly associated with them. Goudie et al. (2014) Happier individuals tend to avoid risk-taking behavior while driving, such as not wearing seat belts. Grant, Wardle, & Across 21 nations life satisfaction was related to more exercise and Steptoe (2009) less smoking, eating fruit and limiting fat intake, and using sun protection, with the first two being consistent across regions and the latter ones showing differences. Hamer and Chida Life satisfaction predicted lower levels of smoking and Body Mass (2011) Index. Hamilton et al. (2007) Hedonic well-being was inversely associated with health behaviors such as smoking and sleep disturbances. Hoen et al. (2013) Found that the beneficial effects of positive affect on survival in coronary heart disease patients were predicted largely by physical activity. Hoogwegt et al. (2013) Positive affect predicted the likelihood of exercise in patients with ischemic heart disease, and this led to fewer deaths at follow-up. Hoyt et al. (2012) Adolescent positive affect predicted fewer risky behaviors such as smoking and drug use in young adulthood, controlling for depressive symptoms and baseline risky behaviors. Kim et al. (2014) High satisfaction individuals used more preventative health services and thus had fewer doctor visits overall. Kim et al. (2016) Psychological well-being predicted physical activity level over the ensuing 11 years in a nationally representative sample old older people in the United Kingdom, with initially active people better maintaining their activity, and initially inactive people becoming more active. Kirkcaldy & Furnham Rates of automobile accidents and deaths were lower in nations that (2000) are higher in positive affect. Koopmans et al. (2010) Happiness was inversely associated with mortality, but this relationship became insignificant when controlled for physical activity and prevalent morbidity. Psychological Well-Being and Health 40

Kubzansky et al. Distress predicted higher Body Mass Index. (2012) Kubzansky & Thurston In predicting the incidence of cardiovascular disease from emotional (2007) vitality, controlling for health behaviors produced the largest drop in the association. Leventhal et al. (2008) High positive affect and low negative affect predicted less smoking relapse over several follow-up periods in individuals in a quitting smoking trial. Pettay (2008) Students high in life satisfaction were more likely to exercise and eat nutritiously. Poole et al. (2011) Daily positive emotions and low feelings of depression were associated with more physical activity as measured by an accelerometer. Sin (2016) Based on a review of the literature concluded that health behaviors such as exercise and not smoking were often the strongest mediators between SWB and cardiovascular disease. Steptoe et al. (2008b) Trait positive affect was associated with lower levels of sleep disturbance. Strine et al. (2008) Life satisfaction was associated with lower rates of obesity, smoking, heavy alcohol drinking, and inactivity, after controlling for socioeconomic factors.

Examples of Findings Showing that Healthy Behaviors are Associated with Health

Walther et al. (2008) Regular exercise reduced cardiovascular events and inflammatory markers in people with cardiovascular disease. Green et al. (2008) Reviews evidence that regular exercise reduces cardiovascular events. Psychological Well-Being and Health 41

Table 8 Moderation of Findings by the Region and Population Studied

Citations Findings

Collins et al. (2009) Positive feelings were associated with health in Taiwan, but the protective effects of life satisfaction for mortality diminished with age. Curhan et al. (2014) Challenged the findings of Pressman et al. (2013) with additional data, and concluded that negative emotions were more strongly associated with poor health in the USA than in Japan, although life satisfaction and global reports of health were similarly associated in both nations. Deverts et al. (2010) Depressive symptoms were more strongly linked to inflammation in blacks than in whites in young middle-aged Americans. Feller et al. (2013) A longitudinal study of over 50,000 participants found that in women life satisfaction predicted a lower risk for cancer, Type 2 diabetes, and stroke, controlling for biological and lifestyle factors. However, in men only an association with stroke was found, and it was nonsignificant after statistical controls were entered. Howell et al. (2007) Review of 150 studies: Generally findings were consistent across age and gender. However, the effects of short-term SWB were stronger for cardiovascular reactivity in older samples, but the effects of long-term SWB on the immune system were stronger in younger healthy samples. Miyamoto et al. (2013) Negative emotions predicted inflammatory markers in the USA, but not in Japan. O'Donnell et al. (2008) Positive affective states were associated with lower inflammatory markers in women but not men. Krijthe et al. (2011) Positive affect was a better predictor of survival in those younger than age 80 than in those over 80, where health seemed to be a major influence on positive affect. Koivumaa-Honkanen Mortality was predicted by low life satisfaction in men but not women. et al. (2000) Lacruz et al. (2011) Life satisfaction predicted longevity over 12 years for men but not for women. Merjonen et al. (2008) Anger was associated with subclinical levels of atherosclerosis in low but not high SES women and men. Pressman et al. (2013) In 142 nations SWB and reports of health were associated, although the association was stronger in low-income countries. Rapp et al. (2008) Found that a diagnosis of depression predicted mortality among the young old, but not among the oldest old. Schwarz (2003) Found that both tense arousal and negative affect were associated with diastolic blood pressure in women but not men. Shirai et al. (2009) Enjoyment in life predicted lower mortality and coronary artery disease in Japan for men but not for women. Smith & MacKenzie Argued that the association of SWB and health ought to change across (2006) the lifespan. Psychological Well-Being and Health 42

Steptoe et al. (2012b) Affective well-being was associated with smaller waist circumference in men, whereas in women it was associated with inflammatory markers and high density cholesterol. For both sexes it was associated with lower triglycerides and lung functioning. Psychological Well-Being and Health 43

Table 9 Moderation by the Type of SWB

Citations Findings

Boehm et al. (2015) Found that life satisfaction reduced risk of mortality, while variability in life satisfaction predicted increased risk of mortality. Brummett et al. Although both positive and negative affect were predictive of survival in (2005) cardiac catheterization patients, positive affect was nonsignificant when negative affect was controlled. Denollet et al. Following stent implantation only positive affect was predictive of clinical (2008) events, but depression/anxiety did not yield independent prediction. Finch et al. (2012) Negative affect predicted subsequent health but positive affect did not. The results showed that changes in NA predicted health beyond long-term levels of NA, but for PA there were only synchronous associations. Friedman & Martin Found in a long-term longitudinal study that high childhood cheerfulness (2011) and sense of humor predicted less longevity. Their sample was extremely high on the positive measures, and thus it may be that their findings indicate the potential negative effects of highly aroused or intense positive affect. Gana et al. (2016) Positive affect was significantly associated with longevity, but negative affect was not an independent significant predictor. Gomez et al. (2004) Highly aroused positive emotions may raise heart rate. Hershfield et al. Mixed emotions, feeling both positive and negative emotions at the same (2013) time, were associated with less health decline over time in aging, and changes in positive but not negative emotions also predicted less health decline. Howell et al. (2007) In a meta-analysis of 150 experimental, ambulatory, and longitudinal studies only small differences were found for the effects of positive versus negative affect on objective health outcomes. Lackner et al. High intensity positive affect can raise heart rate. (2014) McCarron et al. Found that hypomanic men (those with high energy, arousal, and intense (2003) emotions) suffer a substantially elevated risk of cardiovascular mortality. Mroczek et al. Declines in positive affect assessed through experience-sampling that was (2015) related to stressful events was predictive of mortality over 10 years, but emotional reactivity and negative affect were not. Nabi et al. (2008) The highest third of the sample in negative affect experienced more coronary events, but positive affect was not predictive of them. Nealey-Moore et al. Found in an experiment that negative interactions led to increases in heart (2007) rate, systolic blood pressure, cardiac output compared to the neutral and positive conditions. Ortega et al. (2010) In a large longitudinal study over 15 years initial negative affect predicted mortality, but positive affect did not. Papousek et al. Positive affect after a stressor led to quicker cardiovascular recovery, (2010) whereas positive affect before the stressor predicted slower recovery. Psychological Well-Being and Health 44

Ritz et al. (2000) High arousal positive emotions may exacerbate the symptoms of asthma Ryff et al. (2006) Positive and negative well-being show distinct patterns of associations with seven biomarkers, and mirrored patterns for only two. Ryff et al. (2004) Eudaimonic well-being predicted a pattern of healthy biomarkers (i.e., lower levels of salivary cortisol, pro-inflammatory cytokines, and cardiovascular risk), but hedonic well-being did not. Schollgen et al. In a 12-year longitudinal study changes in positive affect were associated (2012) with changes in physical health, whereas changes in negative affect were associated with changes in health only in the less-educated participants. Schwerdtfeger & Long-term activated positive affect was associated with higher heart rate Gerteis (2014) variability, whereas momentary activated positive affect was associated with lower heart rate variability. Momentary deactivated positive affect was associated with heart rate variability. Segerstrom (2014) Found over five years both that negative and positive affect predicted opposite patterns of self-rated health. Shirom et al. (2009) For men high versus low arousal pleasure had the opposite associations with high and low density cholesterol and triglycerides. Skaff et al. (2009) Negative affect predicted next-day blood glucose levels, but positive affect did not. Sugarwara et al. Highly aroused, intense positive feelings may raise blood pressure. (2010) Tsenkova, Love, In a 2-year longitudinal study of older women without diabetes positive Singer, & Ryff affect, but not negative affect, predicted lower levels of glycosylated (2008) hemoglobin. Trudel-Fitzgerald et Emotional vitality was associated with reduced risk of hypertension, and al. (2014) continued after statistical controls, but optimism was not associated with hypertension. Valdimarsdottir & Negative affect was associated with lower natural killer cell levels, but Bovbjerg (1997) positive affect was only associated with more natural killer cells in those who had some levels of negative affect over the day. This interaction pattern suggested that positive affect may moderate or buffer the effects of negative affect. Wiest et al (2011) Life satisfaction and positive affect predicted mortality, controlling for SES and physical health, whereas negative affect did not. In older adults positive affect predicted mortality even controlling for self-rated health and physical activity. For middle-aged participants the predictive value of positive affect did not survive the statistical controls. Xu & Roberts Life satisfaction and positive affect predicted all cause, natural cause, and (2010) unnatural cause mortality, but negative feelings did not. Psychological Well-Being and Health 45

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